The PBF Community of Practice is initiating a collaborative learning program on ‘PBF & Quality of Care’. Health Financing in Africa welcomes testimonies, opinion pieces and presentations of research findings. In this first blog of our series, Shannon McMahon (Heidelberg University, Germany), Christabel Kambala (College of Medicine, Malawi), and Manuela De Allegri (Heidelberg University, Germany)* present findings from two evaluations in Malawi. The authors urge that Respectful Maternal Care (RMC) attracts more attention within the PBF community, and they offer insights into how PBF programming could be used to bolster elements of RMC.

Respectful Maternity Care: status of the knowledge

Respectful Maternity Care (RMC) can be defined as the provision of dignified care to women. In recent years, the topic has featured prominently in maternal health, public health and human rights research. Literature reviews in 2010 and 2015 delineated what disrespectful care looks like. A 2016 review examined what drives disrespect in sub-Saharan Africa (SSA), and several studies (including Abuya 2015 and Sando 2016) have examined the prevalence of disrespectful care during childbirth. While knowledge of the problem is extensive, insights into a solution remain limited and narrow in scope. With one notable exception, studies detailing comprehensive, system-wide solutions are nearly non-existent.

Within the Performance Based Financing (PBF) community, RMC has scarcely gathered attention. A 2017 review on quality of care in PBF programming has noted that, to date, quality indicators have been focused on equipment and infrastructure with far less attention paid to patient-provider interactions or client perceptions of care, although these latter facets are emphasized in the WHO’s 2015 “Vision of quality for pregnant women and newborns”.

We see the challenge of RMC as an opportunity for PBF, and we urge colleagues within the CoP to consider how an output-based approach might address dilemmas related to disrespectful care.

The RMC community has built a compendium of indicators that could be used to measure disrespectful or abusive care. A sampling of questions (and their broader domains) that capture facets of disrespectful care, and could be incorporated into patient surveys and patient-provider observations are presented in Box 1.

We urge the PBF community to consider whether or how indicators like these could be integrated into

BOX 1 - A sampling of indicators* (and their broader domains)that could be used to measure Respectful Maternity Care

Did a woman deliver alone (abandonment) Was a woman allowed to move about during labor (freedom of birth position)

Was a woman allowed to have a labor companion of her choice present (birth companion)

Did health providers discuss a patient’s private health information in a way that others could hear (confidentiality)

Did health providers allow a woman to incorporate cultural practices as much as possible (cultural respect)

Was a woman denied care due to race, ethnicity, age, health status, social class etc (discrimination)

Was a woman or her family asked for a bribe or informal payment (bribes)

existing quality tools (whether during community verifications or facility-based observations). Our teams at Heidelberg University and the College of Medicine have begun having this conversation internally in light of our mixed-methods evaluations of two Malawi-based PBF programs across different districts in the country: the Results Based Financing for Maternal and Newborn Health (RBF4MNH) program and the Support for Service Delivery Integration – Performance Based Incentives (SSDI-PBI) program. Each evaluation revealed problems and opportunities in relation to promoting respect in the context of PBF.

Findings from our two evaluations

In terms of documenting the problem of disrespect, our findings reflect existing RMC literature. Across evaluations, women and community leaders described overcrowding and strained or cursory patient-provider interactions that often entailed demeaning, discriminatory or harsh remarks on behalf of providers.

In both evaluations, respondents reported feeling that providers were tired or overworked, and that they looked down upon the clients they served. The RBF4MNH evaluation placed particular emphasis on maternal care during delivery. In that study, women described how providers did not explain or effectively communicate what they were doing during labor and delivery. Women said they felt ignored. In extreme cases, women described giving birth alone or in the presence of an unskilled companion such as a friend, family member, fellow laboring woman, cleaner or security guard; in three instances, women described how their newborns fell to the floor during delivery as nobody was present to catch their baby. For their part, providers described feeling overworked and undervalued.

In terms of solutions, our evaluations also uncovered reasons to feel hopeful. After three years of implementation, respondents in both evaluations described facilities as having more equipment and better infrastructure (including, in the case of RBF4MNH, enhanced visual privacy via screens); being cleaner; and having a more consistent flow of supplies. Women who sought care in RBF4MNH intervention facilities were more likely to report satisfaction with the level of confidentiality and privacy provided to them during labor and delivery than their counterparts in control facilities. Finally, in both PBF programs, respondents described sensing that the program’s inclusion of patient feedback enhanced provider accountability. In RBF4MNH, this took the form of exit interviews wherein clients were asked a series of questions regarding their encounter with providers. In SSDI-PBI, this took the form of meetings where community members and providers could air grievances and discuss solutions. Whether through exit interviews or collective forums, the process of sharing insights and solutions forced health facility staff to recognize that a patient’s experience of care matters. As one provider said, “Look, when you know you are in part being assessed based on what a woman says, you have to be nice.”

Could PBF contribute more to respectful care?

We have debated within our research team whether it may be feasible for future PBF programs to more pointedly address mistreatment, by incorporating indicators that emphasize respectful care into quantity or quality checklists. We have also posed the following question to providers ‘Could an incentive scheme that rewards respectful care spark lasting changes in provider behaviors and attitudes?’ to which providers responded with caution. Several providers noted that within any given facility there is often a “bad apple” who tarnishes the image of the facility and seems obstinate in their disrespectful approach. Other providers described how a change in incentives could lead to workarounds that don’t eliminate disrespect, but merely shift the role of who is undertaking the disrespectful behavior. For example, overstretched facility staff could recruit those who accompany women to facilities-- in-laws, sisters or mothers --to enact verbally or physically abusive behaviors toward an “uncooperative” laboring woman. We envision that there are many more unintended consequences that could erode trust even amid a well-intentioned, respectful care-focused PBF program.

Despite these challenges, we err on the side of optimism. We recognize that the current dearth of interventions addressing respect is likely linked to the fact that this problem is multi-faceted, emotionally-charged, politically sensitive, and it transcends several tiers of the health system while also demanding long-term, cross-sector collaboration. This makes promoting respect a daunting prospect, but such challenges are not new to those working within PBF.

In fact, we see several parallels between the essential ingredients of a RMC-focused program and the historical experiences of PBF programs. Do both PBF and RMC programs demand a seismic shift in the way a health system operates and views itself? Yes. Do both PBF and RMC efforts require stakeholders from across ministries and sectors to work together in heretofore unheard of ways? Yes. Are PBF and respectful care programs likely to be perceived as burdensome or problematic by providers? Yes. Is the PBF community accustomed to questions and critiques regarding sustainability and cost – perhaps more than any other health intervention in recent memory? Yes it is, and the RMC community may need to brace for this too. Finally, must both PBF and RMC programmers consider how to bring about changes that ripple through several target audiences including: individual clients, households, communities, facilities, district health management teams and multiple ministries? Yes, they do. Given these parallels, could the PBF community harness their tacit and explicit knowledge and devise novel ways to address mistreatment of women? We think so.

*The researchers are engaged in evaluations of the RBF4MNH program and the SSDI-PBI program in Malawi. These evaluations were sponsored by donors including: the governments of the United States and Norway through the USAID | TRAction Project at URC, the Royal Norwegian Embassy in Malawi, and the Norwegian Agency for Development Cooperation (Norad).

In October 2014, the Alliance for Health Policy and Systems Research (AHPSR) launched an implementation research program focused on country experiences with transitioning of Results Based Financing (RBF) initiatives from pilot schemes to full integration into national health systems. The research is being carried out in 11 countries (1). In this blog post, Dr Por Ir, one of the researchers in charge of the overall scientific coordination, reports on research progress to date.

As reported in previous blogposts (here,here and here), the first phase of this research project kickstarted with an introductory protocol development workshop at the Institute of Tropical Medicine in Antwerp, followed by further development of individual research protocols at country level, including data collection tools and consent forms, and their validation by national and WHO ethics review committees. The second and current phase of this research includes identification of key informants, primary and secondary data collection, pulling together the multi-dimensional timeline for the scaling up process, data analysis, and writing up and dissemination of the analytical country case studies.

The intermediary research workshop

The second milestone for the project was another workshop held at the Institute of Tropical Medicine (ITM) in Antwerp, from 22 to 25 June 2015. The aim of the workshop was to bring together lead researchers from the eleven country teams to jointly present and discuss their preliminary research findings, as well as to agree on their next steps towards finalisation of the country case studies. The workshop was coordinated by the scientific team of the Institute of Tropical Medicine (led by Professor Bruno Meessen) and the team in charge of the project within the Alliance (Mrs. Maryam Bigdeli and Mr Zubin Shroff). It was a very useful four day discourse with plenty of cross-country learning on how the RBF schemes have evolved or continue to evolve in different contexts. In brief, the workshop started with individual country presentations on their research progress to date, including preliminary results, followed by questions and comments from other participants. These presentations were complemented by a technical capacity building session on qualitative data analysis and how to write a qualitative research report and scientific paper. Sufficient time was devoted to bilateral technical meetings between individual country lead researchers and the ITM scientific and Alliance team members, which allowed the organizers to better understand the expectations and needs of the lead researchers, as well as lend a deeper insight into country specific issues and help identify how best to address them. The workshop was wrapped up with some general discussions on the common cross-country emerging themes and issues, and planning for the next steps towards finalization of country case studies, including dissemination plans. You can access the program of the workshop here.

A lot of progress achieved… also thanks to youIn general, all the countries have made good progress with their field work and most are on track, with some country teams being more advanced than others. Many have finished their data collection and analysis and have started writing up. Some have already completed their first draft of the research report. A few are still in the process of completing their key informant interviews. We observed three success factors: (i) team commitment, and perhaps, capacity; (ii) clarity and simplicity of the case, partly related to a well thought out protocol; and (iii) the country context and support from key stakeholders. A considerable delay in obtaining ethical approvals was an issue for a few countries.

The research teams have adopted a diverse set of strategies to collect information on the RBF schemes and policy processes, including: review of documents, key informant interviews, focus group discussions, participatory observation… By the way… We would like to take this opportunity to express our sincere thanks to all of you who have dedicated some valuable time to support this study, including participation in key informant interviews and making your key documents and data base accessible. Your inputs have been very valuable!

The workshop raised a number of challenges, many of which were foreseen during the initial protocol development phase. These include the multi-dimensional measurement of the magnitude of scaling up and the development of the related timeline, the application of an appropriate policy framework to determine barriers and enablers to scaling up and the best way to conduct the cross-country comparisons. Early findingsAn output of this research is individual country timelines describing the RBF scaling up process along the different dimensions. The development of these timelines required a creative utilization of the Excel software (you can have a glimpse on this technique here – if you are interested, and do not hesitate to contact Matthieu Antony, our timeline expert!).

Preliminary results from the eleven country case studies reveal some interesting findings on the process and determinants (barriers and enablers) of the RBF scaling up process, some of which cut across countries. While in some countries the entire scaling up process stems from a single RBF scheme, in others, the process is much more complex involving the expansion of multiple RBF schemes. In two countries, the pilot scheme(s) have not been considered for scaling up (yet?). The reported determinants of scaling up vary across countries and two of the emerging determinants are: (i) the international (regional) diffusion of RBF and (ii) the entrepreneurship of the actors, in particular the in-country (pilot) scheme implementer/initiator and policy makers. However, it is too early to draw any conclusion at this stage.

The varying nature of the eleven case studies (with respect to content, type and characteristics of the RBF schemes) and results (i.e. the process, magnitude and determinants of scaling up) make cross-country comparisons challenging. Yet, we hope to be able to finalize and validate a multidimensional descriptive framework, which will have relevance beyond the world of RBF. Next steps As in the earlier stages of this project, the main priority for the scientific coordination team continues to be to maintain close communication with the country teams and to technically assist individual research teams to overcome their specific challenges and help finalize their case studies. All country teams are expected to submit their final country research report before the end of October 2015. In parallel, the coordination team will further elaborate the conceptual frameworks, especially the one for measuring the multi-dimensional magnitude of scaling up.

At the same time, the coordination team will review available draft country research reports (e.g. Tanzania), and provide feedback with relevant comments for further improvement and finalization of the report, and closely follow up the progress of those who are in the process of writing their first draft.

During the workshop, we also discussed tentative ideas/plans for in-country and international disseminations and publications. The in-country disseminations/publications include sharing the report with key informants (in hard copies, through emails or an online version), presentations of key findings at Technical Working Group-Health meetings or during other relevant in-country workshops.

Several suggestions were put forward for scientific communication and international dissemination of research outcomes. The group can capitalize on the Global Symposium on Health Systems Research in Vancouver in 2016, combining both individual presentations with an organized scientific or a satellite session.Journal publications (supplement/series in an open access journal) is another possibility. The ITM team is also eager to develop innovative processes to effectively communicate findings to the main target group: the many policy makers of low- and middle-income countries in charge of scaling up RBF schemes (a community which extends way beyond the 11 consortium countries involved in this particular research program). Of course, we will keep you informed of all such developments on this blog, but if you know of other potential opportunities, please do not hesitate to contact Bruno.All this will no doubt require some extra resources from the AHPSR... but first and foremost, country research reports need to be finalized.

So at this stage, we will encourage the country teams to focus on their main deliverables. And in due time we will come back to you with more insights to the universal challenge of moving from a tiny pilot to a grand national policy.

A number of Results-Based Financing (RBF) initiatives have been (or are being) implemented in Uganda over the last decade, yet so far the RBF movement has not taken off in the country. It’s not really clear why this is the case. The need to bridge this information and evidence gap motivated a team of researchers from Makerere University School of Public Health (MakSPH) and the Ugandan Ministry of Health (MoH) to apply successfully for a grant to understand the extent and determinants of RBF scale-up in Uganda. This case study is part ofamult﻿﻿i-countr﻿﻿y research initiative supported by the Institute of Tropical Medicine (ITM), Antwerp and the WHO Alliance for Health Policy and System Research (AHPSR). This will provide lessons for future RBF scaling up and sustaining the momentum at national and international level. In this blog post, I will zoom in on some ongoing processes.

RBF: “Your flight has been delayed…”

While scaling up of effective health interventions or strategies is considered essential to benefit more people, there is limited documented evidence on how to foster such scaling up process, particularly on Results-B﻿﻿ased Financing (RBF). Many﻿﻿﻿﻿countries are at different levels of integrating RBF﻿﻿﻿﻿in the health system.

Where is Uganda currently in this integration process? Well, RBF in Uganda feels a bit like a plane ready for take-off, but then the plane is postponed for a number of reasons unknown to most passengers. Our job is to find out why and then try to make sure the plane gets in the air, at last. And that it is ensured of a safe journey, then, of course!

Our own (research) focus in Uganda will be to explore the evolutionary journey of four RBF schemes that have been implemented in Uganda over the last 10 years, trying to understand also why there was little integration of RBF into the national health system till now.

The schemes being studied include two supply side pilots namely a World Bank project and the NuHealth project still being implemented since 2011 and ending in 2015. The other two schemes are demand side projects, the Safe Delivery project implemented from 2009 to 2011 and a Safe Motherhood voucher system implemented between 2006 and 2011. This is a qualitative research project, using three data collection methods namely document/literature review, key informant interviews and participant observation.

National consultation workshop on RBF

Recently (16-17 February 2015), a national workshop on RBF took place at Serena Hotel, Entebbe. The meeting was co-organised by the Ministry of Health (MoH) and the Belgian Technical Cooperation (BTC).At the meeting, it became clear that the RBF future looks perhaps brighter than ever in Uganda. The RBF plane might - at last - be ready for take-off, capitalizing, among others, on the Universal Health Coverage drive.

BTC and the Ministry of Health (MoH) are currently launching a new RBF pilot project in two regions in the country. This National Consultation Workshop on RBF was organized in preparation for this project, with support from Makerere University School of Public Health (MakSPH), the Institute of Tropical Medicine, Antwerp (ITM) and WHO Country Office. It was noted by the BTC Project architects that the different schemes (over the last decade) have been implemented as standalone projects with little cross linkage/learning taking place between them. Thus the main purpose of the workshop was to share experiences from implementers, academics and donors such that the new pilot draws lessons from the previous RBF initiatives.

This national consultation workshop provided a unique platform for us to assess the current dynamics of RBF in Uganda. It was an opportunity to explore the MoH’s and BTC’s commitment, readiness and willingness to learn from previous initiatives. It was also an opportunity to understand the proposed RBF design and how it can be leveraged for scale-up nationally.

Will RBF take off this time?

One of the key workshop presentations was made by the Director of Planning at MoH, Dr Isaac Ezati. Dr Ezati provided an overview of the overarching objectives of the Health sector Strategic and Investment Plan (2015/16-2019/20) currently under development. He explained that the overall sectoral objective over this period was achieving Universal Health Coverage (UHC) in line with the Post-2015 development goals. He emphasised that RBF in Uganda is being discussed now in light of the UHC agenda. In fact, he indicated that MoH saw one of the roles of RBF as engendering strategic purchasing for UHC. So it appears that UHC ensures some vital ‘kerosene’ to the RBF movement.

The workshop was another opportunity for various RBF schemes implemented in Uganda thus far to showcase their experiences and achievements. This demonstrated BTC/MoH’s willingness to learn from local experiences. The schemes demonstrated diversity in design and institutional arrangements and provided a wide scope of lessons for BTC to learn from. But as one participant lamented, there was generally little discussion on the costs of RBF pilots, yet high costs have been cited as a barrier for buy-in. To address this challenge, BTC considers hiring a consultant to undertake a costing study for services under the Uganda national Minimum Health care package (UNMHCP).The UNMHCP will be the minimum benefit package under the BTC pilot.

Another presentation from WHO noted that several other health financing reforms such as developing a health financing strategy, finalising fund allocation formula and a National health insurance Scheme (now at Bill level) are taking place simultaneously. This presentation implied that for a pilot to be successful, its design must take into account wider health system issues to enable scale up in entire country. Several health system bottlenecks have to be addressed to allow national scale up of RBF (not unlike for a plane which also needs an entire “eco-system” to function well, both on the ground and in the air, in order to be able to take off, fly and land safely ).

Accordingly, participants discussed a number of constraints such as understaffing leading to heavy workload, poor supervision and poor logistics management. Given these health system bottlenecks, it was emphasised that the BTC model should not be after punishing poor performers to prevent system paralysis. In the meantime, the MoH must articulate a strategy to upgrade facilities with bottlenecks to reach a specific level of functionality to deliver the basic health care package. Otherwise, effectiveness and scalability of RBF in the future would be jeopardized.

Other design parameters discussed related to the utilisation of rewards. It was underscored that allowing autonomy strengthens responsiveness of the health provision and gives room for entrepreneurship. However, this workshop brought to the fore the challenges of extending RBF to public health facilities (which must take place if national scale up is to be achieved). It was noted that almost all previous RBF schemes left out the public health facilities leading to a dearth of experiences on how RBF works in the Public sector. To allay these concerns, the MoH & BTC indicated that the RBF plane will take off from the Private-Not-For Profit (PNFP) airport but will extend to the public sector airport in the second project year. It remains to be seen how this will be realised!

Formation of Working groups…

Participants agreed that it is time to move beyond RBF pilots to national scale up in the country. To facilitate scaling up, the Ministry and BTC pledged to allow for flexibility in the design and implementation. This brought forth other challenges to the scheme as it has to balance demonstrating effectiveness (as accountability to donors) and trying to fit into the country’s learning agenda. Learning during implementation would obviously boost the chances of taking corrective and preventive actions on a timely basis. Indeed, to support the learning function, a Learning Committee supported by MakSPH and ITM was proposed to avoid perverse results as noted in the first Ugandan pilot. BTC assured the participants that there is a budget for these activities.

The workshop did not agree on the design for the BTC pilot. For pragmatic reasons, it was agreed that such technical issues could not be resolved in a plenary. Accordingly, a Technical Working Group under MoH and BTC was proposed to follow up on this issue. However, strangely enough its exact membership composition and timelines were not clearly communicated (air traffic controllers’ communication can still be improved…). This issue has implications considering that the MoH/BTC reported that they were planning to go ahead with the launch of the pilot in a month or so. The fear that this lack of clarity of structure may be detrimental to the buy-in of stakeholders is not far-fetched, especially as engagements with sub-national stakeholders are going into high gear.

RBF: ready for boarding?

As became clear during the workshop, the BTC pilot will start soon. What remains to be seen, though, is the extent to which it will catalyse the momentum towards integrating RBF into the entire national health system. The commitment and enthusiasm from the MOH and BTC representatives was palpable. However, it has to be noted that the proposed RBF design is still a work in progress. Hopefully at the end of all these efforts, Uganda willfor the first time have a RBF scheme reflecting its national health agenda, with attributes rendering it scalable throughout the country.

And once that is the case, I'm sure the RBF plane is set for a wonderful journey in Uganda!

Last October, we informed you of the launch of the multi-country research project "Taking Results Based Financing from scheme to system”. We also expressed our desire to inform you regularly on the progress of this program and to share with you possible lessons, including on the process. The preparatory phase is coming to an end now. In the coming days, research teams from 11 countries will kick off their qualitative research with a major wave of interviews.

As a reminder

Launched by the Alliance for Health Policy and Systems Research (AHPSR) and funded by Norway, this research project aims to examine the experiences of eleven low- and middle-income countries to identify the characteristics and factors that allow (or don’t allow) RBF programs to move from pilot stage to full integration into national health systems. [1] The first stage of this research project mainly comprised the development of research protocols of the eleven country projects and their validation by ethics review committees and in particular WHO’s ethics review committee.The protocol development workshopIn order to launch the research project under the best auspices, a workshop was held at the Institute of Tropical Medicine (ITM) in Antwerp, from 20 to 24 October 2014. The aim of this meeting was to bring together lead researchers from different country teams to jointly work on the development of their research protocols and in particular on defining their research questions. In addition to the principal investigators of each country team, the scientific team of the ITM (led by Professor Bruno Meessen) and the team in charge of the project within the Alliance (Mrs. Maryam Bigdeli and Mr Zubin Shroff) attended the workshop. A representative of the World Bank (Mr Kent Ranson) and WHO (Mrs. Inke Mathauer) were also present. The event worked out the way we wanted: as a platform for meaningful exchange that enabled everyone to relate his/her experience with the research issue to be tackled and to share his/her own reflection and analysis. The organization of a bilateral meeting also allowed the organizers to adjust to the expectations and needs of the various participants. This facilitated in turn a shared and collaborative dynamic to achieve the anticipated results. You can access the program of the workshop here. One of the concerns of the scientific coordinators was to ensure the feasibility of the research (a mistake often made by researchers is that they are too ambitious in terms of the number of questions they want to answer). Consequently, it was decided that each country would have to focus on two research questions. The first one is common to all countries, and will involve describing the nature and process of scaling up RBF. The development of a timeline is one of the tools which will be used to describe the different dimensions of the RBF scaling up process. The second research question aims to be more analytical and varies from one country to another depending on the context and national issues. Finally, the concept of ‘scaling up’ sparked quite some discussion. There is often this somewhat simplistic notion and wish to understand the process of scaling up in its geographical dimension (only). But other dimensions such as the number of services covered or the level of integration in the health system shouldn’t be overlooked either. We also hope to advance the state of knowledge in this respect.Interviews at the country level are about to start After the Antwerp workshop, a remote technical support system was set up to assist research teams. This technical support addresses two major challenges: maintaining a dynamic exchange and sharing process throughout the project; and support the teams in conducting their research. One of the challenges of this research is the rather short time frame to carry it out, due to external constraints. The pressure was therefore high during the weeks following the workshop to finalize and review protocols. During this revision, particular emphasis was placed on the methodological approach - which will consist primarily of a document review and key informant interviews – and on the ethical considerations, including on a valid system to anonymize the interviews (at the workshop, we clearly identified the sometimes highly political nature of a reform like RBF). More importantly, several tools were used to ensure smooth communication between support teams (ITM and AHPSR) and research teams after the workshop. For example, the creation of a shared Dropbox folder with research teams facilitated the sharing of key methodological documents related to: (i) the application of theoretical and analytical frameworks, when analyzing health policies, (ii) the methods and practices for in-depth interviews, (iii) the literature on the scaling up process of policies, and (iv) stakeholder analysis methods. We have also started using webinar technology. Over the last days, country teams have received the reports of the WHO ethics review committee. The comments were minor and are currently being integrated. Several teams also received the report of their national ethics committee. This will allow researchers to begin their round of interviews very soon. So if you are active in one of the 11 countries studied (or have played an important role in one of these countries in the past), maybe the interviewers will soon come knocking at your door. We hope that you will give them a warm welcome. Your knowledge matters: it is by documenting and analyzing the experiences in your country that we can produce lessons for all. Note:1. The countries are: Armenia, Burundi, Cambodia, Cameroon, Chad, Kenya, Macedonia, Mozambique, Rwanda, Tanzania, Uganda.

This blogpost introduces a multi-country research project looking at how at country level, Results Based Financing (RBF) schemes move from pilot to full integration into national health systems. The study is led by the Alliance for Health Systems and Policy Research and scientifically coordinated by the Institute of Tropical Medicine (ITM) and will be carried out by national research teams of eleven countries.

Worldwide, more than 30 low or middle-income countries are today developing, within their health sector, experience with so-called RBF strategy. While a few of them have already moved to a full-fledged national policy, most of them are still in pilot stages. This large international movement is facilitated and boosted by a number of forces and positive synergies: political will, aid agencies’ leadership and financial resources, enthusiasm of experts, commitment of major stakeholders, pro-active knowledge management…The main goal of every RBF scheme is to improve the performance of the health system (measured in terms of quality of the health service delivered, coverage rate…). The ultimate goal of every - successful - pilot scheme is to be scaled up. From a knowledge management perspective, though, a pilot scheme which failed to improve some target indicators is actually still a success if the operational lessons which have been drawn from the experience allowed stakeholders to improve the national health system. This is an outcome which matters for an RBF strategy, as many have argued that its transformative power is one of its key attributes. A key metric of the ‘success’ of an RBF experience should therefore be its ability, through the core principles it promotes, to reinvigorate the national health system. One can foresee transformations/scale up on many different dimensions.

Launch of a multi-country research project

The possible journey “from scheme to system” will be the main focus of a multi-country research project coordinated by the Alliance for Health Policy and Systems Research and the Health Economics Unit of the Institute of Tropical Medicine. This research program is sponsored by NORAD, the Norwegian Aid Agency.

The call for proposals launched by the Alliance sparked quite some interest: 34 research teams submitted a proposal. Eleven countries have been selected – you can discover which ones by clicking here.(1) Selected research teams have been informed. The next step will be a protocol development workshop to which the principal investigators of the eleven countries will be invited. Together, we will explore the commonalities across the 11 cases and assess whether we can adopt a common framework and select a limited number of common research questions.

After approval of the protocols by ethical committees, each national research team will document how the journey from scheme to policy is going in their respective country (although among the 11 countries, we have also interesting stories of pilot schemes which did not materialize into national policies). While our sampled countries are mostly from sub-Saharan Africa (the most dynamic continent, as far RBF is concerned), we are happy to have also three experiences from outside Africa. In Africa, we will cover a nice mix of settings: a few post-conflict countries, some Francophone and Anglophone countries, a mix of small and big countries.

Our communication strategy

While the PBF Community of Practice is not formally involved in this research at this stage, we will make sure throughout this project to keep you informed about the progress being made. We are indeed very aware that moving from scheme to system is a challenge that some of you are already facing today. So you may learn from what we discover… but we also value the knowledge you will share with us. This interaction with you will take different forms, but our online forum and this blog will be major tools (do not hesitate, for instance, to contact us if you want to write a blogpost on the situation in your country or just share some reflections). We will also seize opportunities offered by face-to-face encounters to discuss on this topic with you (as we did already in Buenos Aires and as we will do again at the Cape Town symposium, in a satellite sessionco-organized with the World Bank).

This promises to be an exciting journey. We hope that you will be with us all the way long.

Note:(1) We are very aware that some readers of this blog post are disappointed by the non-selection of their proposal. Proposals went through a systematic appraisal system set up by the Alliance. Feel free to contact Mrs Maryam Bigdeli at the Alliance to know the reasons why your proposal has not been selected.

Isabelle LangeThe Harmonization for Health in Africa Communities of Practice are today firmly installed in the global health landscape. The Financial Access to Health Services CoP (FAHS CoP) for instance gathers more than 700 experts committed to progress towards universal health coverage through strategies such as user fee removal, health equity funds, health insurance… In this blog, Isabelle Lange, medical anthropologist at the London School of Hygiene and Tropical Medicine and FEMHealth researcher reports findings of her qualitative research on the FAHS CoP itself.“[The FAHS CoP online group] is effective for sharing information, for networking, and for the exchange of experiences…. It’s- it’s extraordinary…. First, through the community I discovered, I had the opportunity to exchange with a lot of people and now after the workshop, I think that they are friends… I will try to maintain these relationships despite…. Even if the relationship is there and exists you have to reinforce it and care for it.” – Policy Maker, North Africa

More and more actors in the global health community are tapping into the growing range of resources to widen their networks and information bases. Communities of Practice (CoPs) fit into this trend, and as they ﻿become a more popular tool in today’s information management methods in global health﻿, there is the sense that the utilization of the Internet and strong content can bridge individuals to create or strengthen a community. A CoP then could provide resources for knowledge sharing and potentially also for informed health policy and systems change, breaking the traditional direction of north to south information flow and communication barriers across professional silos. However, achieving this model can be a complex process dependant on many contextual variables; exploring the processes of a particular CoP can shed light on its contribution to health policy as a mechanism for knowledge exchange. This was one of my ‘assignments’ under the FEMHealth project. The CoP FAHS and the FEMHealth: three years of collaboration

The FEMHealth project was a 3-year multi-disciplinary evaluation of maternal health user fee removal policies in Morocco, Mali, Burkina Faso and Benin. I carried out a semi-external view of FAHS CoP as a part of the health policy research. The health policy analysis aimed to understand the origin of the policies in these countries and why similar measures were taken around the same time period to reduce the financial burden of childbirth costs on women and their families. There we explored whose voices were heard, which agendas were pushed and what evidence was influential in driving these strategies. The FAHS CoP offered an arena to deepen that research by observing the current debates and actors, in addition to serving as its own study area on this mechanism as a vehicle for knowledge sharing and transfer. It also offered a channel to connect the FEMHealth researchers in with the wider community interested in their topic. As FEMHealth had supported the establishment of the CoP, it was also interested in understanding how well the CoP was meeting its goals of knowledge creation and exchange. In my capacity as anthropologist working on the health policy analysis research, I attended three FAHS CoP workshops (in Bamako 2011, Marrakech 2012 and Ouagadougou 2013) and alongside informal exchanges and observation of the content during those meetings, carried out in-depth interviews with the facilitators and about 25 participants – following up with a selection of them over the years to gain an idea of the value of the CoP within their professional and personal lives.

CoP workshopsAccording to my informants, the CoP workshops cut across geographic, disciplinary and linguistic boundaries that frequently hamper knowledge exchange amongst different profiles of actors. The magic formula for this was, according to participants: an appropriate participant body – with engaged, knowledgeable actors there to learn and make a difference, not just to collect per diems; dynamic, skilled facilitation; plenty of time for informal exchange (during coffee breaks or on field visits); quality simultaneous translation between French and English; pertinent technical content; and a format that allowed for questions, discussion, learning and problem-solving, not just presentations and “being spoken at.”

A particular wish of participants was to have the beneficiary community voice present in the discussions, based on the feeling that they did not have space carved out to be legitimately heard in the usual pathways of decision-making. “I think that often we meet just amongst us, actors in the ministry of health, or those who implement the program, without taking many things into account because we can’t imagine the perspectives of the user or beneficiaries of the service”, stated a West African policy maker. “They have to be there to tell us ‘what you did like this, should have been done like this instead.” This view was echoed in reference to other stakeholder groups, including health workers and researchers, underlining the absence of meaningful cross-silo exchanges in typical/existing professional structures. Importance of the online communityThese workshops are an important part of the FAHS CoP identity – strengthening the membership and committing to action a core tenet of the knowledge-sharing mandate of CoPs. What was clear, however, was that the CoP workshops had another special component: the online community that served as a base to these workshops. This group offers a continuity and home to the technical content and face-to-face exchanges that similar conferences did not have. While many of the attendees at the workshops were not CoP members (at the time), the community thread ran through the conference and made its presence:member participants were asked to summarize debates and presentations which were posted to the 700+ subscribers, who could then continue the discussion via email and feed back to the conference attendees with further thoughts and questions. One workshop participant who is also a community member said, “I see these face-to-face meetings (as) very important. That's what feeds new community members and that feeds the online life to the next workshop. And so there are these two mechanisms – face-to-face - that are then a good trigger for online knowledge movement and communication and discussions.”

In its own right, the online community served as a valuable link to work being done in health financing on a broader scale than many members were involved in their day-to-day professional lives. Access to grey and academic literature, unpublished experiences, and especially the diverse opinions of fellow community members on these pieces proved to be a reason why the online group was valued and, for some, ‘boosted confidence’ in their own capacity and was considered a unique contribution to the resources available in this field.

Further reflections and future stepsThe enactment of policy-relevant knowledge in more dynamic ways – through interactive meetings, continuous facilitation, editorials, and community building, among others – was seen to be a strong point of the community of practice model in providing both personal and professional benefits to members. But questions remain about strategies that can create a lasting impact in a world where many are over-worked and access to a surplus of material and resources can at times seem to be a burden rather than a benefit. The CoP offers a reference point and an organizational component to information, people and networks, which, as one agency participant says, is “the key to the whole thing…. It’s knowledge dissemination, knowledge production, capacity building.” But, he continues, “a community of practice is not just there for the management, but to build something.” Over the past three years we have watched the FAHS CoP grow into a network of more than 700 individuals and as an organization have seen its presence at numerous conferences and affiliation with other professional bodies. Discussions around its ideal future structure emphasize its need to remain non-normative, independent and be member-driven, not only member-responsive, in order to be able to contribute to shaping an environment that constructively and innovatively brings about positive policy advances through knowledge sharing.

Read the accompanying policy brief for the facilitators’ perspectives on growing a CoP, and don’t hesitate to get in touch with any thoughts or ideas.

Jean-Benoît FalisseIt will soon be 27 years that the Bamako Initiative was launched and community participation became a core component of health policy in Africa. Through eight interviews, one personal reflection, and your many comments in French and English, what was once the "magic bullet" of community participation turned out to be a complex topic. The debate is certainly not closed but this blog post series is coming to an end. Here is my own (subjective) conclusion; it brings more questions than answers.

First of all, the series has put the Bamako Initiative in the continuum of International Health (“global health” we would say today) strategies and policies. The inspiration of the Bamako Initiative seemed a little blurry at first, somewhere between the Chinese barefoot doctors and the 1977 Alma-Ata Conference on Primary Health Care. However, the interview with Walter Kessler shows us how, in the early 1980s, Doctors Without Borders had already set up experimental health committees in Chad and Mali. They would soon inspire the Bamako Initiative. Susan Rifkin and Agostino Paganini explain the relative success of the initiative in its early years, with the involvement of UNICEF in the field and under charismatic and dynamic leadership of the duo formed by Dr. Mahler (WHO) and Mr. Grant (UNICEF). As already foreshadowed by Doctors Without Borders' experience with the health stores in the 1980s, the type of community participation advocated at the Bamako conference came along with the introduction of user fees, which states justified by their inability to pay for everything because of the debt crisis. From its inception, the Bamako Initiative had two faces, which even this series that focused on community participation has not been able to totally disjoint. On the one hand, there is community empowerment and self-management; and on the other hand, there is a more expensive access to care. The question that still arises today, which is answered in the negative by Sophie Witter, is whether it makes sense to continue to link the two?

The Bamako version of community participation -with the health committee as a central mechanism- spread like wildfire in Africa. However, the local context was often neglected, and strategies that worked well in some places worked much less so in others. There is no one size fits all, as illustrated by the contrasting experiences of the DRC where the idea of participation was easily accepted, and neighbouring Uganda where the principle of community health management was going against traditional governance. Once past the initial enthusiasm, community participation initiatives, especially when their support by states or international organisations was discontinued, portended a disengagement of the states vis-à-vis the health of their populations. Community participation cannot be imposed. However, to carry on the idea of "health for all", humanize relationships to health-care services, and develop non-technocratic and holistic approaches to health-care, direct and deep community participation remains a promising track. It is in this spirit that the third recommendation of the recent Dakar Conference proposes to strengthen the capacity of the community to make it a “real partner for the analysis of its health problems, and the planning, implementation and evaluation of health interventions.”

As I write this post, the Bamako Initiative is dead. It has been so for a long time already. Its user fees component is roundly criticized. Its (resource-intensive) community participation component, which has often been hijacked by politicians and was much slower than expected to yield visible impacts, has not been the panacea the global health community once thought it would be. Nevertheless, the idea of ​​giving people a more central place in their health-care system continues to live on. In different parts of the globe, new forms of social accountability and direct involvement of citizens in their own health are taking place. In order to work, these must take greater account of local situations and be of direct interest to the people who are getting involved. The community needs to see an interest in participating. This is basically what the IRC officials, who implemented the Tuungane programme, which generalized a participatory approach to rebuilding communities (and their health services) in Eastern DR Congo, and Dr. Canut of Burundi, who explained how community health workers can become important parts of the health system if they are given incentives, were saying. Community participation cannot be improvised; the example of the ASACO in Mali shows that continued investment and a solid organization are needed to sustain community participation. Once past the naive vision of the community that would ex nihilo organise itself for better health-care, the challenge seems to find ways to encourage and induce participation and maintain it without manipulating it.

In this context, research about community participation still seems in its infancy. More studies are needed and they will probably need to use mixed methods in order to reach conclusions that go beyond the description of cases. It is essential to better understand the link between health facilities and their users. How can we build people's participation? How does it lead (or not) to health improvements? If the process is not linear, how should we report about it? 27 years after the Bamako Initiative, we still know very little about the impact of community participation strategies on health and access to health; especially compared to recent and less recent studies on other major global strategies such as (community-based) health insurance, performance based financing, or fee exemption.

The elephant in the room of this series is the question of power. Community participation is fundamentally about power, which is often disputed among medical staffs, medical authorities, and the population (and within the population itself). Community participation (in health) is not limited to questions that are strictly medical. The Malian adventure, the timing of the set-up of community participation mechanisms in Uganda, or the ASACO system in Mali remind us that participation is political. It is a question of governance. If this were not the case, if the dimension of power was removed from community participation, what we would observe is a pastiche of participation, an empty shell that would quickly lose its appeal. Rather than continuing to avoid the issue of power and call community participation a strictly "technical” question, it is essential to recognize that participation involves the redistribution of power and decisions on the organization and definition of health-care services.

Finally, this series reminds us that there is no magic bullet in international public health. Just like performance-based financing, fee exemption, and all the other ‘grand strategies’ in global health, community participation in itself is not sufficient to achieve health for all. The concept needs to take account of field realities and adapt, and even then, it remains only one element to be combined with other strategies to respond to the many different issues of quality universal health care.

The Alliance for Health Policy & Systems Research, a global partnership hosted within WHO, is about to launch a new implementation research programme focused on results-based-financing (RBF). A few experts of the Performance Based Financing Community of Practice (CoP PBF) attended a preparatory meeting in Geneva on 23-24 January. In this blog post, they report on the two-day event.The Alliance for Health Policy & Systems Research is known for its commitment to enhancing the dialogue between researchers and research users, policy makers in particular, in developing countries. As readers of this website know, the Harmonization for Health in Africa communities of practice fully embrace this agenda. Late December, several of us were contacted by Joe Kutzin (WHO, Geneva - Department of Health Systems Governance and Financing) and Nhan Tran (Alliance) to join them, together with other RBF and provider payment reform experts, for a consultation meeting to prepare a new call dedicated to implementation research on RBF. Olivier Basenya, Por Ir, Bruno Meessen and Laurent Musango made the trip to Geneva. Participants were asked to assist the Alliance in identifying main implementation research questions related to the scale up and integration of RBF initiatives into national health systems and policies, and in identifying priority countries where such research would have a greater impact. After two days of intense interactive deliberations, it was decided that the research program will focus on the enabling factors and barriers for RBF (pilot) schemes to be scaled up and integrated into national health systems and policies, taking into account RBF design features and implementation process, health systems characteristics, and socio-economic and political context. We agreed that the importance (extent) of the scaling-up and integration would be assessed on several dimensions such as population and service coverage, institutionalization, financial integration in the public budget and so on. While some countries have been relatively successful in making progress on this multidimensional scale, others have been encountering quite serious obstacles in doing so.We are hopeful that this research program will bring interesting insights into how one needs to successfully navigate the policy process, combining efficiency with ownership and a sufficiently inclusive process, with the aim of strengthening health system and moving towards Universal Health Coverage (UHC). We know from previous meetings that national PBF champions are looking for guidance in this respect. All participants made relevant contributions, with some as delicate as the tiny paper cranes produced by Professor Winnie Yip from Oxford University (picture illustrating this blog post). Others (like ourselves), conveyed their message in a more straightforward way. One of the things we emphasized was that it’s vital to ensure that the research process involves country health authorities in such a way that it allows them to reflect on the extent to which they have actually achieved health systems strengthening via the integration/scale up of their pilot schemes – a shift from scheme to system and policy. Interestingly enough, the research program will not have a purely instrumental aim. Eligibility criteria will also allow applications by research teams willing to document processes which were wrong from the start, e.g. a pilot project with insufficient or no (government) ownership, or one that failed to be scaled up. It was suggested that the research areas should be a mixture of countries that have advanced in RBF implementation at national level, countries in pilot experiences phase and some others with a demand side component.

The planning of the Alliance is ambitious. We expect the call to come out soon, so keep an eye on their website (ourselves, we will of course inform CoP experts through our online forum). We hope that many of you will apply and submit letters of intention as this is a research program fully in line with priorities pursued by the PBF CoP.

Allison KelleyIn this blog post, Allison Kelley presents a descriptive research project being carried out by experts from two communities of practice – Financial access to health services and Performance-based financing - in twelve Francophone African countries. One of the project’s innovations is its collaborative approach. Universal health coverage (UHC) – is higher than ever on the agenda, both nationally and internationally. Presidents, key development partners, and even international NGOs are all pushing for UHC. What consensus! And yet – as is often the case – the devil is in the details – and in this case, in the many and ever expanding number of health financing schemes in African countries: user fees, budget allocation, funding inputs, community-based health financing schemes, fee exemptions for certain population groups, exemptions for the poorest, performance-based financing… Just to illustrate my point, one of our experts has already inventoried 29 different health financing schemes in Niger! Such fragmentation in national health financing, without even mentioning the challenges of quality and human resources, can leave one feeling perplexed in the face of all the fervour around UHC. How can the various pieces of the health financing puzzle be assembled to constitute a coherent picture at a national level? In many countries, there are a multitude of different actors involved in the planning and implementation of such health financing schemes (HFS), all with their own objectives. Many are unaware that they are in some way contributing to UHC in their country. They may also be lukewarm at the prospect of collaborating or being “rolled up” into some sort of larger scheme. The diversity and confusion around various aspects related to the governance, objectives, intervention level, target groups, financing sources, available budgets, eligibility criteria, management and performance of these various HFS are such that no one today has the whole picture. And yet this picture would seem essential if a country truly wants to progress toward a more efficient and equitable national health financing system. It would also help to identify population groups that are less well covered, and those that may have double coverage (and those who stand to gain from such double coverage), inefficiencies, etc. I’d even suggest that having this full picture should be a prerequisite to defining and putting in place a national health financing strategy. A multi-country study Thanks to French Muskoka funding (with additional resources from Cordaid), experts from two CoPs – financial access to health services and performance based-financing – are carrying out a collaborative research project in 12 sub-Saharan Francophone African countries. Their goal is to map this tangle of HFS. At the country level, we hope that this mapping exercise will create a clearer picture of the complexity of health financing schemes in-country. By comparing across the 12 countries we hope to be able to begin to trace some recurrent situations, or patterns, that we can interpret as favourable or unfavourable (using existing knowledge of health economics and political economy) toward expanding UHC. A collaborative process from A to Z If this research is modest in terms of its scientific objectives (descriptive documentation only using existing secondary data and knowledge held by experts), it is more innovative from a methodological perspective: from its conception to its end, it is a collaborative process. Back in Spring 2012 (yes, it can take some time to turn an idea into a reality…), we organised a “virtual brainstorming” using the on-line discussion groups of two CoPs. We asked members to suggest priority research topics for a proposal to be submitted for French Muskoka funding (UNICEF WCARO). We then put the suggested topics to an electronic vote by members. The outcome was uncontested: the top priority topic was to better understand how to link up the ever-growing number of HFS at the national level in a coherent move toward UHC. Since so many countries were interested in the topic, we opted for a more open research model that would capture a maximum number of experiences (rather than focus in on 1-2 countries): a sort of overview of what exists, not unlike the inventory carried out to prepare for the FAHS CoP’s first workshop in Bamako. We launched a call for individual experts to carry out the research at the country level. Because the Muskoka funding covered francophone countries (and only some of those at that), we ended up with candidates for 10 countries: Benin, Burkina Faso, Guinea, Ivory Coast, Mali, Niger, Central African Republic, Democratic Republic of the Congo, Senegal, Chad, and Togo. Our open model then led us to include two “non-Muskoka” countries, Burundi and Cameroon, thanks to Cordaid funding. After signing the contract in Spring 2013, we were able to thus put the research team in place. A study guide was drawn up and shared with this team, and then improved through their comments and suggestions. A product of real joint collaboration! What’s next The research is finally underway. Researchers on the team are in continuous discussion on challenges, tips, and strategies for obtaining the financial data they need… The results from this first phase of research – a mapping of HFS in 12 countries and a synthesis of the situation across these countries – will be presented at the March AfHEA conference in Nairobi shared more broadly by mid 2014. This picture of almost a quarter of the countries in Africa should suggest some more general lessons and perhaps even some recommendations. In early 2014, we will begin preparing the second phase of the research (to take place in 2014-15). Our intention is to develop a more in-depth questionnaire that we will test in at least one country. Phase 2 will thus take a “deep dive” in a number of countries (providing sufficient funding is available). We will attempt to document efficiency and equity losses due to overlapping and duplicative HFS and to identify areas for improvement. We expect that this second phase will produce concrete recommendations for each country studied in-depth. This type of research project is definitely uncharted territory for the CoPs. Its the first time we have solicited member involvement for this sort of documentation. What we find especially interesting is getting involved in an area of research that is relatively less popular – multi-country studies and cross-country analysis. Between individual studies on health financing in a particular country and the tables WHO produces annually on international health spending, we think there is room! And CoPs may just have a role to play, given their members span almost every country on the African continent. Still, our ability to succeed at such endeavours will depend on factors like our ability to coordinate amongst ourselves, and to help each other out where necessary. We certainly plan to document this original, collaborative research model along the way. So stay tuned for preliminary results in early 2014. Here’s hoping that we can contribute to making more of the existing multiple and diverse HFS to expand UHC.